Provider Demographics
NPI:1962913251
Name:DOMENECH, SHARON
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHARON
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:255 PINE GROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-2613
Mailing Address - Country:US
Mailing Address - Phone:347-698-1024
Mailing Address - Fax:
Practice Address - Street 1:1061 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6728
Practice Address - Country:US
Practice Address - Phone:508-996-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10258OtherMEDICARE